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3. integumentary system
3. integumentary system
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  2. 2. • The integumentary system consists of the skin and its accessory structures, including the hair, nails, sebaceous glands, and sweat glands. • The skin is the exterior covering of the body. It weighs more than 6 pounds in the average adult, and covers more than 3,000 square inches. • It is the largest organ of the body. It is supplied with blood vessels and nerves.
  3. 3. Skin • one of the largest organ in our body • Forms barrier b/n internal external environment • Participate in many function of the body • Continuous in external opening of the body • provide noninvasive window to observe the body’s level of functioning • Covers the body
  4. 4. • The skin consists of 3 layers: – Epidermis- non vascular outermost layer, continuously dividing cells – Dermis- takes the largest portion of the skin and provides strength and structure. It consists of glands (sebaceous, sweat), hair follicle, blood vessels, and nerve endings – Subcutaneous tissue (hypodermis)- the inner most layer. contains major vascular networks, fat, nerves, and lymphatics
  5. 5. Factors influencing skin integrity • Immobility is the major factor leading to pressure sore development . • The pt who is confined to bed & unable to change position is at greatest risk . • Trauma most likely occur – over the prominent areas – weight bearing areas
  6. 6. 6 Epidermis Dermis Subcutaneous tissue Skin appendage Layer of the skin
  7. 7. 7 Epidermis  The most outer layers of stratified and squamous epithelium  Consists of four layers Stratum cornium Stratum lucidum/ granulosum Stratum germinativum/ spinosum Basel layer  Thickness – range from o.lmm to 1mm/1.6mm  Regenerates almost every 3-4 wks
  8. 8. 8 cells of epidermis Keratinocyte Melanocyte Merkel cell Langerhans cells
  9. 9. 9 Basement membrane of the skin Separate dermis from epidermis Rate ridge ( undulated furrows)  Anchors epidermis Found at junction of dermis and epidermis Permit free exchange of essential nutrients It is finger print on finger tips
  10. 10. 10 Dermis • Largest portion of the skin • It consists of • Blood vessels • Lymphatic • Nerves • smooth muscle • Cells • fibroblast • Macrophage • Mast cell
  11. 11. 11 Subcutaneous tissue • Below the dermis • Attaches skin to muscle & bone • Stores fat • Regulates temperature • Provides shock absorption
  12. 12. 12 Glands of the skin Sebaceous glands • Found every where on the dermis except on palmar and plantar surface • Secretion stimulated by sex hormones Sweat glands • Eccrine sweat glands • Apocrine sweat glands Ceruminous glands
  13. 13. 13 Nails • Composed of keratinized and horny layer • Color ranges from pink to yellow or brown depending on skin color • Pigmented bands in nail bed is normal for dark skinned people • Protects ends of fingers and toes
  14. 14. 14 Hair Grows over most of body except lips, palms & soles Color is inherited & depends on amount of melanin Protects and warms the head
  15. 15. Function Of Skin • Protection- protection of underlying structures from invasion by bacteria, noxious chemicals and foreign matter. • Sensory perception- transmits pain, touch, pressure, temperature, itching, etc. • Fluid balance (excretion)- absorption of fluids and evaporation of excess. • Temperature regulation- produced heat released through skin by radiation, conduction, and convection • Vitamin synthesis- skin exposed to ultra violet light can convert substances necessary for synthesizing vitamin D3 (cholecalciferol). • Aesthetic- provides beauties and appearance
  16. 16. ASSESMENT OF CLTENTS WITH SKIN PROBLEMS 16 1. History 2. Physical examination 3. Diagnostic evaluations
  17. 17. History 17 • Identification/biographic data • Onset of symptoms • Location of symptoms • Medicament history • General medical history • Travel history • Family or house hold contacts
  18. 18. History cont’d 18 Presence of symptoms and It’s characteristics Sever itch Scabies Atopic eczema Contact dermatitis Mid itch Psoriasis Drug eruption Bullus pemphigoid Pain -vasculitis and pemphigus ( large bulla)
  19. 19. Physical examination 19 Technique Inspection Palpation Observation Requirements Good light Pen light Warm and private room Done glove Drape
  20. 20. 20 Inspection Inspect the skin for 1. Color of the skin 2. Vascular changes 3. Skin lesions
  21. 21. 1.Color of the skin Increased pigmentation…deposition of Melanin Loss of pigmentation…… leprosy Redness ……allergy Yellow …….carotenoids Brown ……. melanin Blue ……. ..reduced hemoglobin Red ………. ..oxygenated hemoglobin 21
  22. 22. 22 2.Pallor Absence or decreased normal skin tone and vasculature Best observed from conjunctive, mm, palm and sole Cause – anemia, DHN
  23. 23. Pallor
  24. 24. 24 3.Cyanosis  Bluishness of the skin  Best observed from lips bucal mucosa Tongue Type Central cyanosis Peripheral cyanosis
  25. 25. Cyanosis 25
  26. 26. 26 Possible causes of; Peripheral cyanosis • Anxiety • Cold exposure • CHF
  27. 27. 27 Possible cause of central cyanosis CHF Venous obstruction Advanced lung disease Congenital heart disease Respiratory obstruction Indicates Cellular hypoxia
  28. 28. 28 4.Jaundice  Yellowish Ness of the skin  Occurs due to increased blirubin  Noted from- sclera and mucus membrane  Suggests liver disease Excessive hemolysis of RBC
  29. 29. Jaundice 29
  30. 30. 30 Palpation Palpate the skin for; • Moisture • Temperature. • Texture • Mobility and turgor • Tenderness • Edema
  31. 31. • Moisture  Dryness may indicates hypothyroidism  Oiliness may indicates acne, sweating Temperature • Generalized warmth occurs in fever, hyperthyroidism • Generalized coolness as in hypothyroidism • Local warmth as in inflammation Texture • roughness or smoothness 31
  32. 32. 32 Skin lesion The most prominent characteristics of dermatological problems 80-100% of persons living with HIV/AIDS develop dermatological conditions May be very disabling, disfiguring and even life-threatening Vary in shape and size Classified according to appearance and origin Assessment of skin lesions
  33. 33. Herpes vircilla virus
  34. 34. Tinea pedis
  35. 35. acne
  36. 36. Adverse effect of topical corticosteriods
  37. 37. pso
  38. 38. Assessing the general appearance of the skin • The general appearance of the skin is assessed by observing (Inspection) color, skin lesions, and vascularity. • On palpation skin turgor and mobility, possible edema, temperature, moisture, dryness, oiliness, tenderness, and skin texture (rough and smooth).
  39. 39. Color change: can be hyperpigmentation, hypopigmentation or depigmentation 1. Redness- fever, alcohol intake, local inflammation due to increased blood flow to the skin. 2. Bluish color (cyanosis) - decreased oxygen supply due to chronic heart and lung disease, exposure to cold, and anxiety
  40. 40. Cont’ed… 3. Yellowish color (jaundice) - increased serum bilirubin concentration due to liver disease or red blood cell haemolysis - Uremia- renal failure 4. Brown-tan- Addison’s disease: cortisol deficiency stimulates increased melanin production - Birth mark, chloasma of pregnancy (face patches), and sun exposure 5. Pale: Albunism- total absence of pigment melanin • Vitiligo- destruction of the melanocytes in circumscribed areas of the skin
  41. 41. Benign skin condition-vitiligo
  42. 42. Diagnostics test • Skin biopsy: removal of a piece of skin by shave, punch, or excision technique for a microscopic study of the skin to determine the histology of cells to rule out malignancy and to establish an exact diagnosis. • Patch testing: performed to identify substances to which the patient has developed an allergy. • Potassium hydroxide test (KOH): helps to identify fungal skin infection
  43. 43. Diagnostics test… • Gram stain and culture with sensitivity test: helps to identify the organism responsible for an underlying infection with the effective drug identification • Slit Skin Smear (SSS): to identify the causative agent of leprosy (mycobacterium leprea)
  44. 44. Disorder of the skin I . Inflammatory and allargic skin disorders – Acne – Psoriasis – Atopic dermatitis (eczema) – Contact dermatitis II. Bacterial infections – Impetigo – Boil (furuncle) – Carbancle – Cellilitis
  45. 45. Disorder of the skin… III. fungal infections – Candidiasis – Tinea captis – Tinea corporis – Tinea pedis (atlet's foot)
  46. 46. Disorder of the skin… IV.Viral infections – Herpes simplex (cold - sore) – Herpes zoster (shingles) – Warts
  47. 47. Inflammatory and allergic condition A. Eczema/Dermatitis - It is a chronic pruritic inflammatory disorder affecting the epidermis, and dermis commencing in infancy, often persisting throughout child hood but eventually remitting and some times recurring in adult life. • They are a non-infectious inflammation of the skin and it can be acute, sub-acute or chronic.
  48. 48. Con’ted …. • Causes – The exact cause is unknown – Imbalance of the immune system with an increase in the immunoglobulin “E” activity and deficient of cell mediated delayed hypersensitivity. • Can be exacerbated by infection, bites, pollen, wool, silk, fur, ointments, detergents, perfume, certain foods, temperature extremes, humidity, sweating and stress
  49. 49. Hypersensitivity reactions HA(MSN) 56
  50. 50. Sign and symptom • An acute stage eczema shows redness, swelling, papules, blisters, oozing and crusts. • In the sub-acute stage the skin is still red but becomes drier and scalier and may show pigment change. • In the chronic stage -lichenification, -excoriation, -scaling and cracks are seen
  51. 51. Types of eczema Atopic eczema - is a chronic relapsing skin disorder that usually begins in infancy and is characterized principally by dry skin and pruritis, consequent rubbing and scratching lead to lichenification • This patient has a genetic predisposition for hypersensitivity reactions such as asthma, allergic rhinitis, and chronic urticaria. – The eczema comes and goes – The eczema triggered by dryness of the skin, infections, heat, sweating, contact with allergens or irritants and emotional stress.
  52. 52. Atopic eczema… • Mostly affected sites are elbow and knee folds, wrists, ankles, face, and neck; in some cases it can be generalized
  53. 53. Atopic dermatitis
  54. 54. Atopic dermatitis
  55. 55. Seborrhoic eczema - is a very common chronic dermatitis characterized by redness and scaling that occurs in regions where the sebaceous glands are most active, such as: –Scalp, border of forehead/scalp –Behind ears, above and in between eyebrows –In nasolabial folds, Sternum –In between the shoulder blades, in axillae –Groin , Perianal area
  56. 56. Seborrhoic eczema… –Under the breast , umbilicus and in body folds –Pts often complains of oily skin –The eczema comes and goes –In HIV patients, the eczema can become very widespread and easily super infected
  57. 57. Infective eczema • which occurs as a response to an oozing skin infection. • Common sites are the foot, and ankle region • Causative organisms are usually staphylococci/ streptococci • Vaseline use aggravates this condition
  58. 58. Contact eczema: • is caused by contact of the skin with an irritant or an allergen. • Vaseline commonly causes: Vaseline dermatitis. • Common causes of irritant contact eczema on hands, arms and legs are excessive use of H2O, soap (especially if not washed off properly) detergents, chemicals, sunlight, jewellery, dyes, bleaches, perfume, nail polish/remover, etc
  59. 59. Contact dermatitis
  60. 60. Sign and symptom of eczema/ dermatitis (general) • Itching • Redness, dry skin, lichenification, excoriation, scaling skin • Papules, blisters, oozing and crusts • Color change
  61. 61. Management (general) • Stop the use of irritants (contact eczema) • Mild topical steroid such as hydrocortisone 1% cream twice daily until lesions clear. • In severe itching use antihistamines E.g.: promethazine 25mg at night, chlorphenaramine 4mg at day time/night
  62. 62. Mgt cont… • In bacterial super infection use KMNO4 solution, Betadine solution, antibiotics • Explain to the Patient, and Parents that not serious and will disappear in time. • Keep finger nails short and covered at night • Use non greasy or non moisturizers (seborrhoic eczema)
  63. 63. Mgt cont… • An imidazole cream twice daily/ketaconazole 200 mg/d 1-3 weeks (seborrhoic eczema) • The vicious circle of itch – scratch – lichenification – itch needs to be broken , (atopic eczema)- conscious effort to stop scratching • In photo allergies – sun protection by wide rim sun hat, long sleeves, high collar, sunglasses, stay indoor, sunscreen, umbrella, etc • Keep the site clean
  64. 64. Acn e - Is a common disorder of the sebaceous gland associated with excess production of sebum and blockage of the duct resulting in a variety of inflammatory manifestations. • Common in puberty and usually regresses in early adult hood • Patient complain of oiliness of the skin. - Occurs on the face, upper trunk and shoulders - Appears to be multiple inflammatory papules, pustules and nodules
  65. 65. Acne … • It can be very mild to be very severe: - they blend together to form large inflammatory areas with cysts and scar formation. Cause-genetic, hormone and bacteria play a role
  66. 66. Cont. . Sign and symptom • Red nodules, cyst , red papules, scars, pustules, keloids • There may be mild soreness, pain or itching • Inflammatory papules, pustules, pores acne cyst, scarring Diagnosis • Clinical – Cyst formation, slow resolution, scarring – Common at puberty and common of all skin conditions
  67. 67. Management • Stop the use of vaseline, oil, ointment, greasy cosmetics which further blocks sebaceous ducts. • Benzoyl per oxide 5-10% gel or tretinoin 0.01- 0.1% cream or gel apply at night. • Salicylic acid 1-10% in alcoholic solution for removal of excess sebum. • For pustular/inflammatory lesions use topical clindamycin 1% solution, erythromycin 2% lotion
  68. 68. Management … • In severe cases use systemic long term antibiotics like doxycycline 100mg twice daily until substantial improvement followed by 100mg once daily until acceptable. • Surgical treatment – extraction of comedones, incision and drainage of large fluctuant, nodulocystic lesions
  69. 69. Psoriasis • Is a chronic recurrent, hereditary, non infectious disease of the skin caused by abnormally fast turn over of the epidermis • The turn over may be up to 40 times than normal and as a result the epidermis is not able to develop normally, therefore it doesn’t allow formation of the normal protective layer of the skin.
  70. 70. Psoriasis… • Skin become red, inflamed, and the scales are thicker than normal • It produces a so called candle-wax phenomenon, when you scratch such a patch it becomes silvery white. • Sites can be extensor areas of extremities especially elbow, knees, buttocks, shoulder and scalp
  71. 71. Generalized psoriasis
  72. 72. • Cure is there but it reoccurs • Occurs at any age but 10-35 years is common mostly. • Periods of emotional stress and anxiety aggravate the condition. Sign and symptom. • May itch severely in body folds covered with silvery scales • Finger and toenails may show pitting and thickening • Associated arthritis
  73. 73. Management • Explain to the Pt the recurrent nature of the disease. • Salicylic acid 2-10% ointment twice daily to reduce scaling • Moisturizers (Vaseline, paraffin oil, or cream) • Treat any super infection with KMNO4 , or antibiotics if necessary • Psoriatic arthritis NSAIDS E.g.: Ibuprofen, Indomethacin, and ASA • Methotrexates as a last option in sever cases.
  74. 74. Dermatitis • Inflammation of the skin as a result of contact with an irritating substance such as a chemical, foreign substance, medication, or contact with a plant, such as poison ivy. • The skin may become reddened, irritated, and itchy. The usual causes are allergic reactions.
  75. 75. • Often the patient has a history or a family history of asthma, allergy, or eczema. Some later symptoms may be the result of scratching of the skin. Often the cause may be a drug reaction, the body’s immune system reacting to a medication.
  76. 76. SIGNS AND SYMPTOMS • Rash on the affected skin area from contact with the offending substance • Pruritis from histamine release from mast cells • Erythema and edema • Vesicles where the substance came in contact with the skin • Hyperpigmentation from irritation from scratching
  77. 77. INTERPRETING TEST RESULTS • RAST testing may be done to determine allergens. • Patch testing
  78. 78. Treatment • Treatment involves determining, if able, the triggers that began the flare, and avoidance of the same. • Treatment aimed at each symptom will help to decrease discomfort. • If the dermatitis is widespread, IV medications, steroids, or antihistamines may be necessary to resolve the flare. • Topical corticosteroid cream, gel, or lotions will decrease the symptoms.
  79. 79. NURSING INTERVENTION • Avoid irritants that caused the dermatitis to prevent recurrence. • Allow for healing and prevent bacterial infections. • Cool compresses. • Use protective gloves and clothing. • Wash hands often. • Explain to patient: • Keep the skin moist. • Keep nails short to diminish scratching. • Warm, not hot, showers. • Use mild soap. • Apply moisturizers